Workforce issues
service can develop and maintain effective systems and processes for responding to patient safety incidents in order to learn from them and improve patient safety. The PSIRF replaced the Serious Incident Framework. The PSIRF demonstrated a complete change
to the way in which organisations approached and learned from incidents. It involves a ‘considered and proportionate’ response using a range of system-based approaches.7 A systems-based approach views the
work system, which includes a wide variety of different elements – such as the external environment; organisation; internal environment; tools and technology; as well as the tasks, people and work processes (including physical, cognitive and social/behavioural aspects). It looks at the relationship between these elements and the resulting outcomes in healthcare. Investigations, held at a variety of different NHS Trusts, found that the most common consequences of fatigue described by staff were: l Medication errors l Impaired decision making l Reduced attention and vigilance l Incivility (rude and disrespectful behaviour)
A Medical Defence Union survey (n 481) in 2025 found that 22% of members felt sleep deprived on a daily basis and a further 19% on a weekly basis. Specifically, 35% said tiredness had impaired their ability to treat patients and 34% said tiredness may have played a part.8 During the investigation by HSSIB, they were told that fatigue affected the judgement and
performance of staff. When they are tired they struggled to concentrate, took longer to perform routine tasks and were less able to control their emotions. Staff said that communication, compassion and teamwork suffered, impacting on interactions with patients and other staff. It was also reported by Troth, following a
survey of night shift workers, that 42% reported microsleeps while driving home, and 48% reported knowing that they were too tried to drive but driving anyway.9
Conclusion
It is perhaps no surprise to those who have worked long shifts on stressful wards and departments, especially overnight with fewer staff, that patient safety incidents are now connected to fatigue. In other safety critical industries, fatigue is a recognised hazard which impairs the sufferer and their ability to do their job. To mitigate and reduce the opportunity for harm, other industries have fatigue risk management systems based on scientific principles and knowledge, as well as operation experience. The investigation undertaken by HSSIB demonstrates there is awareness in healthcare but there is no consideration of suitable mitigation factors. Stakeholders considered that healthcare was a long way from considering and managing the risk of staff fatigue at this level. The culture in the NHS is too far away,
at present, for fatigue management to be implemented; some senior leaders interviewed by HSSIB felt it could be destructive. They
suggested that the culture needed to accept that it was safe for staff to speak up and ensure that low levels of staffing were suitably tackled. Staff who were engaged with the
investigation felt that it would be very useful if the CQC were to include fatigue within it’s inspection framework. However, some experts also expressed that it was not yet time to regulate for staff fatigue.10
l The need for a clear understanding of what fatigue is in healthcare.
l Clarity on what actions healthcare providers should be taking to manage fatigue risk.
l Training regulatory staff in understanding fatigue.
l Limitations in how healthcare may understand and manage risk across the healthcare system. This has been explored in HSSIB investigations on safety management: ‘Safety management systems’ and ‘Safety management: accountability across organisational boundaries.’
l Unintended consequences for staff and organisations if fatigue risk management measures are not implemented correctly.
It seems that there is a great deal of work still to do, although any staff member asked to show how it has affected them and their ability to deliver care, will have experience of the harm that fatigue can do in clinical situations. CSJ
References 1. Health Services Safety Investigations Body report 2025 The impact of staff fatigue on patient safety. Accessed at https://www.hssib.
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June 2025 I
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